This document discusses the classification and management of genitourinary fistulas. It begins with an introduction defining a fistula and classifying them based on organ of origin and termination point in the urinary tract. It then describes various types of genitourinary fistulas involving the bladder, ureter, and urethra. The remainder of the document covers etiology, clinical features, investigations, prevention, and surgical and non-surgical management of genitourinary fistulas.

1. Dr.SMRUTI RANJAN PATANAIK
GUIDE – DR . NINA MISHRA

2. INTRODUCTION
• A fistula represents an extra – anatomic
communication between two or more body
cavities covered by their own epithelia, the
communicating tract is also epithelized. This
tract may also open at the skin surface.
• Classification of urinary fistulas is generally based
on organ of origin in urinary tract and termination
point of fistula.

3. TYPES OF GENITO URINARY FISTULAS
BLADDER
1. VESICO VAGINAL
2. VESICO UTERINE
3. VESICO CERVICAL
4. VESICO URETHROVAGINAL
URETER
1. URETERO VAGINAL
2. URETERO UTERINE
3. URETERO
CERVICAL
URETHRA
1. URETHRO
VAGINAL

6. Vesico-vaginal fistula
Vesicovaginal fistula (VVF) is an abnormal opening
between the bladder and the vagina that results in
continuous and unremitting urinary incontinence..
VESICO – VAGINAL FISTULA

7. HISTORY
MOST COMMON ACQUIRED FISTULAS
ANCIENT EGYPT, BEFORE 2000 BC
DESCRIBED BY SIMS

8. CLASSIFICATION OF GENITOURINARY
FISTULA ACCORDING TO FISTULA SITE,
SIE, SCARRING AND VAGINAL LENGTH
• SITE –
1. Type 1 : Distal edge of fistula > 3.5cm from
external urinary meatus (EUM).
2. Type 2 : > 2.5cm – 3.5cm from EUM
3. Type 3 : > 1.5 cm – 2.5cm EUM
4. Type 4 : < 1.5cm from EUM

9. • SIZE –
• Size < 1.5 cm in the largest diameter.
• Size 1.5 cm – 3 cm in the largest diameter.
• Size > 3cm in the largest diameter.
CLASSIFICATION OF GENITOURINARY
FISTULA ACCORDING TO FISTULA SITE,
SIE, SCARRING AND VAGINAL LENGTH

10. • SCARRING AROUND AND VAGINAL LENGTH.
1. None or mild fibrosis around fistula and /
vaginal length > 6cm.
2. Moderate or severe fibrosis around fistula
and reduced vaginal length.
3. Special cases e.g. Post radiation, ureteric
involvement, previous repair.
CLASSIFICATION OF GENITOURINARY
FISTULA ACCORDING TO FISTULA SITE,
SIE, SCARRING AND VAGINAL LENGTH

11. Classification
according to site of fistula
CLASSIFICATION ACCORDING TO SITE OF FISTULA
1. HIGH FISTULA –
JUXTA CERVICAL
VAULT (VESICO – UTERINE)
2. MID VAGINAL FISTULA
3. LOW FISTULA –
BLADDER NECK (URETHRA INTACT)
URETHRAL INVOLVEMENTS ( SEGMENTAL, i.e Partial Bladder Neck
Loss )
COMPLETE BLADDER NECK LOSS (CIRCUMFERENTIAL FISTULA)
4. MASSIVE VAGINAL FISTULA
Encompasses all three fistulas and may include one/both ureters
in addition.

12. CLASSIFICATION ACCORDING TO SIZE
• SMALL -- < 2Cms
• MEDIUM – 2 – 3 Cms
• LARGE – 4 – 5 Cms
• EXTENSIVE -- > 6 Cms

13. CLASSIFICATION ACCORDING TO
COMPLEXITIES
SIMPLE VVF
• < 2 – 3 cms in size.
• Supra Trigonal
• No H/O of pelvic
malignancy and radiation.
• Vaginal Length is normal.
• Healthy Tissue
• Good Access
COMPLEX VVF
• > 3 cms in size.
• Trigonal or Below
• H/o – Pelvic Malignancy or
radiation
• Vaginal length is shortened
• Associated with scarring
• Involving Urethra, Vesical
Neck, Ureter
• Previous unsuccessful
attempt at repair.

14. AETIOLOGY
GENITOURINARY
FISTULAS
OBSTETRICAL GYNECOLOGICAL ACCIDENTAL
ACQUIRED CONGENITAL

15. ECTOPIA VESICAE
(CONGENITAL)
• The posterior wall of the urinary bladder is exposed to
the exterior.
• It is caused by the failure of the anterior abdominal wall
and anterior wall of the bladder to develop.
• It is due to inability of the mesoderm of the primitive
streak to migrate around the cloacal membrane.
• Aberrant Ureter and persisting uro genital sinus.

17. ETIOLOGY
• OBSTETRICAL TRAUMA ( 95 %)
- Prolonged and obstructed labour---pressure necrosis of bladder
neck or trig one leads to delayed onset of urinary fistula during
second week of puerperal due to constant and prolonged
compression of bladder neck by jammed up presenting part
against symphysis pubis as in cases of obstructed and prolonged
labour .
- Till mid 6th decade of last century; this was the commonest
cause of obstetrical urinary fistula . change in the management
of CPD , contracted pelvis , malpresentation
,Uterine inertia has made it a remote complication.
- Introital stenosis secondary to female circumcision ,
cephalopelvic disproportion, an android pelvis , malnutrition ,
orthopaedic disorder contribute to dystocia .
- operative(iatrogenic)--- forceps (kielland’s /high forceps
application ,destructive instruments used to deliver stillborn
infants and criminal abortion.
Gishiri cuts(nigra)

19. POST SURGICAL
-
-
-
-
GYNAECOLOGICAL-----(0.5 -1 %)
Abdominal hysterectomy(1/1300patients)Simple /
redical(Werthem’s.) Vaginal hysterectomy.
Myomectomy—cervical and broad ligament fibroids.
Laparoscpic --- fulguration, too much heat near bladder or
ureter
- Caesarean section
- Sling operation for-incontinence of urine.
- Repair of Anterior vaginal wall prolapse --
(e.g.colporrhaphy)
- Manchester Repair.
- Circlage operation with separation of bladder at the level of
internal Os.
Vaginal cystectomy.
Cystoscopic---Bladder biopsy , Endoscopic resection , laser
procedure

20. • Radiation induced fistula (associated with Rx for Cancer
Cervix or other pelvic malignancies)
• Vaginal foreign bodies
• Forgotten Pessaries
• Direct trauma from masturbation or
automobile accidents
• Miscellaneous- Late stage of malignancy of genital
tract involving urinary tract.
• Tuberculosis , Schistosomiasis , Perforating bladder
calculi , Endometriosis , Syphilis ,
Lymphogrannuloma venerum and idiopathic and
congenital cause.
OTHER CAUSES

21. CLINICAL FEATURES
• VVF usually presents with constant/continuous leakage of
urine per vagina (True Incontinence) – Classic Symptom.
• Leakage after surgical injury occurs from the first post
operative day.
• Most commonly recognized in first 10 days after operation
and less commonly between 10th to 20th postoperative day.
• Obstetric Fistulas– Symptoms take 7-14 days to develop.
• Post Pelvic Radiations Fistulas– Delayed Onset of Leakage,
takes months to years.
• Small Fistulas– Leakage in certain positions and can also pass
urine normally.
• Large Fistulas– Patientmay not void at all, but leak.

22. • Excoriation of Skin leads to fungal infection , irritation ,
dermatitis.
• Recurrent cystitis or UTI.
• Unexplained fever ,hematuria ; discomfort in flank and
suprapubic region
• As urea is split by vaginal flora, the vaginal pH becomes
alkaline, which precipitates greenish-gray phosphate crystals
in the vagina and on the vulva.
• The patient can become a social recluse; disrupt sexual
relations; and lead to depression, low self-esteem, and
insomnia.
CLINICAL FEATURES

23. HISTORY
• Age and socioeconomic status of the women.
• Previous gynecological surgery/radiotherapy.
• Previous h/o prolonged labour/trauma during
child birth.
• Time of occurence.
• History of Urine Leakage.
• Timing of leakage, amount of leakage.
• Voiding per urethra apart from leakage.
• Any leakage of feces, gas leakage.
• Any attempt of previous repair of fistula.

24. PHYSICAL EXAMINATION
• General Examination
• Per abdomen examination – surgical scars
Vulval Inspection -- Leakage of urine and
excoriation of vulva, escape of watery discharge per vaginum of
ammoniacal smell is characteristic, sudden and excoriation of the
vulval skin, varying degree of perineal tears may be present.

25. • P/S Examination –
• Sim s speculum and sim s position
• Pool of urine in vagina and fistulous opening may be
visible.
• Location, number and size of fistula is to be noted.
• In case of bladder neck fistula involvement of internal
sphincter may also be associated .
• There may be associated or combined fistulas e-g
vesico vaginal , vesicocervical and ureteric fistula.
Bladder mucosa may be visibly prolapsed through a big
fistula

27. DIAGNOSIS
• SPECIAL TESTS –
1. CATHETER TEST – comes out from the vaginal
orifice of vagina.
2. CLICK TEST – metal catheter in bladder gives
click with metal probe passes through vaginal
orifice of fistula.
3. METHYLENE BLUE DYE TEST
4. MODIFIED METHYLENE BLUE TEST– no pads but
dye is observed directly.
5. DOUBLE DYE TEST ---

28. DYE TEST TO DETECT
THREE SWAB TEST To, differentiate from ureterovaginal
and urethrovaginal
INTRAVENOUS
UROGRAPHY
Ureterovaginal fistula
RETROGRADE
PYELOGRAPHY
Exact site of Ureterovaginal fistula
CYSTOGRAPHY Vesiciouterine fistula
SINOGRAPHY
(FISTULOGRAPHY)
Intestinogenital fistula
HYSTEROSALPINGOGRAPH
Y
Vesicouterine fistula
USG, CT, MRI Complex fistula
CYSTOURETHROSCOPY Location of fistula in relation to
ureteric orifice

29. DYE INSTILLATION
• Although the ideal method of confirming
genitourinary fistulas is by direct visualization,
there are instances where physical
examination and inspection are unrevealing
these circumstances, bladder instillation of
visually distinct solutions such as methylene
blue, sterile milk and indigo carmine can often
indicate the location.

30. • When the presence of a urinary fistula is uncertain, or the location
in the vagina cannot be identified, a modified tampon test or
three swab test is recommended.
• During testing, gauze is packed sequentially into the vaginal canal.
A diluted solution of Indigo Carmine/Methylene blue is instilled
into the bladder in a retrograde fashion, using a catheter.
• After the patient has engaged in 15 – 30 minutes of routine
activity, the gauze is removed serially from the vagina and
inspected for the presence of dye.
• The specific gauze coloured with dye suggests, where in the vagina
a fistulous tract is located – a proximal or high location in the
vagina for the innermost gauze, and low or distal fistula for the
outermost.
• If the distally placed gauze is stained with dye, however, it is
important to confirm that it was not contaminated by stress
incontinence

34. INVESTIGATIONS
• CBC and Urine analysis
• Blood chemistry for serum creatinine , blood urea and fasting
blood sugar.
• Urine for culture and sensitivity.
• Intravenous pyelography (Ureteric fistula ,ureteric stricture
and hydronephrotic changes)
• Ascending pyelography to fortify the findings of IVP.
• Modern imaging technique CT and MRI have limited value as
Cystoscopy ( performed)gives maximum and to the point
information about size ,shape , number and location of
fistulas.
• Biopsy from the edge of fistula cystoscope guided when it is
suspected to be – malignant/post radiation/tubercular
/schistosomiasis

36. Fistula opening in
Bladder
Cystoscopy

42. PREVENTION
• OBSTETRIC FISTULA
PRIMORDIAL PREVENTION
1. Girl’s Education
2. Women’s Empowerment
3. Increase the age of marriage
4. Nutritious diet since childhood

43. PREVENTION
• PRIMARY PREVENTION
1. Availability of family planning method services.
2. Strategy to make motherhood safer should be
followed.
3. Good antenatal care.
4. Watchful progress of labour.
5. Trained birth attendants.
6. Transportation of emergency obstetric care.

44. PREVENTION
• SECONDARY PREVENTION
1. Early recognition of CPD and prevention of
obstructed labour.
2. LSCS in indicated cases.
3. Avoidance of difficult forceps and destructive
operations
4. Prolonged catheter drainage in prolonged
obstructed labour.

45. PREVENTION
• RADIATION FISTULA
1. Proper dose and technique of irradiation
2. Packing of the vagina
3. Midline Block

46. IF WE SUSPECT FISTULA IS GOING TO
FORM AFTER OBSTRUCTED LABOUR
OR DESTRUCTIVE OPERATION
• Insert an indwelling catheter and start continuous
closed drainage.
• Ensure a high fluid intake.
• Mobilise her early, always keeping the bag below
her bladder.
• After 7- 10 days , examine her anterior vaginal
wall in Sim’s position with speculum.
• If her bladder is still bruised or necrotic, then
leave her catheter in and remove only when
healthy tissue is seen in next examinations.

47. PREVENTION
• SURGICAL FISTULA
1. Adequate exposure during surgery.
2. Minimize bleeding and hematoma formation
3. Dissection in correct planes.
4. Wide mobilisation of the bladder.
5. Intra op retrograde filling of bladder.
6. Cystourethroscopy during surgery.

48. MANAGEMENT
1.CONSERVATIVE MANAGEMENT
2.MEDICAL THERAPY/INTERVENTION
3. NON SURGICAL INTERVENTION
4.SURGICAL THERAPY/INTERVENTION

49. CONSERVATIVE MANAGEMENT
• INDICATIONS
1. Simple fistulae
2. < 1cm in size
3. Diagnosed within 7 days of index surgery.
4. Unrelated to carcinoma or radiation.
CONTINUOUS BLADDER DRAINAGE
1. By transurethral or supra pubic catheter.
2. Duration upto 30 days
Small fistula may resolve spontaneously, if fistula decrease in
size then drainage for additional 2-3 weeks
If no improvement in 30 days then will need surgery.

50. MEDICAL THERAPY/INTERVENTION
• Estrogen Replacement Therapy – optimise
tissue vascularization and healing in post
menopausal patient.
• Local Estrogen Vaginal Cream – 2-4 grams placed per
vaginally at bedtime once a week for 4-6 weeks in
those who are hypo estrogenic.
• Acidification of Urine– to diminish risk of cystitis,
bladder calculi formation, vitamin C 500mg orally
TDS

51. • Antibiotics – to prevent infection of the site.
• Other Drugs – Combination of antiseptics like
methenamine, phenyl salicylate, methylene blue,
benzoic acid.
Parasympatholytics like atropine sulphate ,
hyoscyamine sulphate.
Sitz Bath
Barrier ointment such as zinc oxide or vaseline
application
In treatment of perineal and ammoniacal dermatitis.
MEDICAL THERAPY/INTERVENTION

52. NON SURGICAL
INTERVENTION/THERAPY
• ELECTROCAUTERY FULGURATION –
Fistula small in size (pin hole openings)
Vaginal and cystoscopic route – fulguration –
foley’s catheter placement for 2-3 weeks.
FIBRIN GLUE – useful and safe for intractable
fistula
LASER WIELDING WITH ND YAG LASER –
Fulguration and transurethral catheter for 3
weeks.

55. SURGICAL MANAGEMENT
• PRINCIPLES
1. Timing of Repair
2. Route of Repair
3. Suitable equipment and illumination
4. Adequate exposure and patient positioning
5. Excision of fistulous tract
6. Use of suitable suture material
7. Sufficient post operative bladder drainage.

56. TIMING OF REPAIR
• Dictum is that , the best time to repair fistula
is at its first closure during index surgery.
• Obstetric Fistula – 3 months following delivery
• Surgical Fistula – if recognised within 48 hours
or immediate repair. Otherwise repaired after
10 – 12 weeks.
• Radiation Fistula – after 12 months.

57. PREOPERATIVE CARE
• Improvement of general conditions
• Continuous bladder drainage
• Antibiotics
• Estrogen cream
• Topical creams for ammoniacal dermatitis

59. PREOPERATIVE ASSESSMENT
• Local assessment of the fistula best done 1 – 3
days before the repair – fistula status.
• Urine Routine Microscopy
• Urine Culture and Sensitivity
• Cystoscopy
• Urethroscopy
• Voiding Cystourethrogram
• Intravenous urogram
• Retrograde Pyelogram
• Urodynamic Studies
DEPENDING ON
CAUSE

63. PRINCIPLE OF FISTULA REPAIR
• Adequate exposure of fistula tract with debridement
of devitalised and ischaemic tissues .
• Removal of involved foreign bodies or synthetic
materials from region of fistula(if possible).
• Careful dissection and anatomic separation of the
involved organ cavities.
• Water tight closure.
• Use of well vascularized ,healthy tissues flaps of
repair(traumatic handling of tissue).
• Multiple layer closure.
• Tension free, non-overlapping suture lines

64. Vaginal
approach,
Vaginal Flap
splitting
Latzko technique
Saucerization
Transvesical
•Vertical cystotomy
•Excision of VVF track
transvesically
Transperitoneal
Combined
VAGINAL APPROACH ABDOMINAL APPROACH
SURGICAL MANAGEMENT

65. PEDICAL INTERPOSITION
GRAFTS
• For repair of big fistula, post radiation fistula
AIM –
•To support fistula repair
•To fill dead space
•To bring in new blood supply to area ofrepair.
GRAFTS –
•Martius graft-labial fats and bulbocavernousmuscle
•Gracilis
•Omental graft
•Rectus abdominis
•Peritoneal flap graft

66. ABDOMINAL APPROACH INDICATIONS
• High inacessible fistula
• Multiple fistula
• Involvement of uterus or bowel
• Need for ureter re-implantation
• Complex fistula
• Associated pelvic pathology
• Surgeon preference

67. VAGINAL APPROACH ADVANTAGES
• Avoids laparotomy and splitting of the bladder.
• Recovery is shorter with less morbidity.
• Less blood loss and postoperative bladder irritability.
• Postoperative pain is minimal.
• Results as successful as those of the abdominal
approach are.
• Vaginal shortening may be an issue with some types
of vaginal vvf repairs, including the latzko operation.

68. ABDOMINAL APPROACH
ADVANTAGES
1.Inadequate exposure related to a high or retracted fistula in a narrow
vagina.
2.Close proximity of the fistulous tract to the ureter.
3.Associated pelvic pathology requiring simultaneous abdominal
surgery.
4.Multiple and recurrent fistulas.
5.Supratrigonal location.
6.Surgeon's inexperience with vaginal surgery.
7.Tension free suturing.
8.Mobilization of bladder and excision of scar tissue.
9.Closure in layers.
10. Interposition of grafts particularly omentum and muscle.
11.Good exposure and spot less bright light.
12.surgeons experience with best route as well as
location/size/number/associated uretericfistula.

74. A: A longitudinal incision is placed in the bladder dome. B: The incision is
extended around the fistula. The fistulous tract and its vaginal orifice are
completely excised. C: Interrupted delayed-absorbable sutures are used to
close the vagina in one or two layers.

75. D: Continuous delayed-absorbable suture closes the bladder mucosa
longitudinally. E: A suprapubic catheter is placed into the bladder in an extra
peritoneal location.

76. F: The bladder muscularis is closed with delayed-absorbable continuous or
interrupted sutures. G: An omental flap can be interposed between the bladder
closure and the vaginal closure.

80. A: Ureters have been catheterized. An incision through the
vaginal epithelium is made circumferentially around the
fistula. B: The vaginal epithelium is widely mobilized from
the bladder. The scarred fistula tract should be excised.

81. C: A continuous (or interrupted) delayed-absorbable suture
inverts the mucosa into the bladder. D: A second suture line
is placed in the musculofascial layer to reinforce the first.
Vaginal epithelium is trimmed and approximated

82. Latzko technique for a closure of a simple vesicovaginal
fistula. (A)A circumferential incision is made around the
fistula. The fistula is not excised. B: The vaginal epithelium
is mobilized approximately 2 cm from the fistula.

83. C: Delayed-absorbable interrupted mattress sutures are
placed parallel to the edge of the fistula tract to invert it
into the bladder. D: One or two additional rows of suture
approximate the musculofascial layer of the bladder.

84. The vaginal epithelium is closed transversely with
interrupted delayed-absorbable sutures.

85. A: The lateral margin of the labia majora is incised vertically) The fat
pad adjacent to the bulbocavernosus muscle is mobilized, leaving a
broad pedicle attached at the inferior pole.

86. C: The fat pad is drawn through a tunnel beneath the labia minor and
vaginal mucosa and sutured with delayed-absorbable sutures to the
fascia of the urethra and bladder. D: The vaginal mucosa is mobilized
widely to permit closure over the pedicle without tension. The vulvar
incision is closed with interrupted delayed-absorbable sutures.

87. ADVANCED SURGICAL TECHNIQUES
• LAPAROSCOPY – Done mostly through the
transvesical procedure.
• ROBOTIC SURGERY – Complex and multiple
fistula , or patients having dense adhesions.

88. POST OPERATIVE CARE
• The bladder should be drained for 14 – 21 days.
• Excellent hydration to ensure irrigation of the
bladder and to prevent clots that could obstruct
the bladder.
• Catheter blockage should be prevented so that
there is no bladder distension and tension on the
suture lines.
• Supra pubic catheter may be used for fistula in
bladder.
• Cystogram is to evaluate the integrity of the
bladder before discontinuing the bladder drainage.

89. INSTRUCTION ON DISCHARGE
• Contraceptive advice, i.e.Spacing for 1- 2years.
• Abstinence for 3 months.
• Maintain hygiene.
• If pregnancy occurs elective C section is indicated at
when fetus attains maturity.
• Woman who had repair of obstetrical fistula may
develop UTIs , DUB and other gynaecologyical
problems like other people, should go for medical
advice.
• When pelvic surgery is indicated should be done by
experienced surgeons.

90. FOLLOW UP
• 2-3 Weeks after fistula repair is an adequate
time period for post operative imaging.
• At 6 weeks and 12 weeks clinical examination
is to be done.

91. FACTORS AFFECTING SUCCESSFUL
OUTCOMES
• Adequate exposure of the operative field should be
obtained to avoid inadvertent organ injury and to ensure
early identification of any injury occurred..
• Minimize bleeding and hematoma formation.
• Widely mobilize the bladder from the vagina to diminish
the risk of suture placement into the bladder wall.
• Adequate urinary tract drainage and catheterization.
• Treatment and prevention of infection (Appropriate use
of antimicrobials).
• Wide mobilization of the vaginal epithelium to expose the
bladder

92. POST OPERATIVE COMPLICATIONS
EARLY
1. Excessive Bleeding
2. Surgical Wound infection
3. Urinary tract infection
4. Continued urine leakage through fistula
LATE
1. Risks of abdominal and pelvic adhesions (if abdominal approach is
used)
2. Risks of dyspareunia and tenderness (if vaginal approach is used)
3. Reduced vaginal length/ shortening and stenosis(if vaginal
approach is used)

93. EUA GUIDELINES 2016
• Surgeons involved in VVF repair should have
enough training, skills and experience to select an
appropriate procedure for each patient.
• Attention should be given to skin care, nutrition,
rehabilitation counselling and support prior to
and following fistula repair.
• If a VVF is diagnosed within six weeks of surgery,
consider catheterisation for 12 weeks after the
causative agent.

94. • Tailor the timing of fistula repair to the
individual patient and surgeon requirements
once any oedema, inflammation and tissue
necrosis or infection, are resolved.
• Where ureteric re – implantation or
augmentation cystoplasty are required, the
abdominal approach is necessary.
EUA GUIDELINES 2016

95. 6.Ensure that the bladder is continuously drained
following fistula repair until healing is
confirmed
• (10-14 days for simple and/or postsurgical fistulae;
• 14-21 days for complex and/or post-radiation fistulae).
7.If urinary or faecal diversions are required, avoid
using irradiated tissue for repair.
8.Use interposition grafts when repair of
radiation associated fistulae is undertaken.
EUA GUIDELINES 2016